1. Palliative Care: Depression and Anxiety Hong-Phuc Tran, M.D,

2. Learning Objectives Identify signs and symptoms of depression Discuss risk factors for depression Understand differential diagnoses of depression Learn management of depression Explain signs and symptoms of anxiety Understand management of anxiety

3. Depression: Introduction Depression is often under-recognized and under- treated in terminally ill patients Persistent depression is not normal for patients near end-of-life or with terminal conditions and should be treated Prevalence of depression is 1-40% in palliative care settings Up to 58% of patients with cancer have depression

4. Signs and Symptoms of Depression Sad or depressed mood Insomnia or sleeping too much Anhedonia Guilt or hopelessness Low energy Difficulty thinking or concentrating Anorexia or eating too much Psychomotor retardation Recurrent suicidal ideations, plans or attempts When the above symptoms occur for 2+ weeks, then diagnosis of major depression is made

5. Examples of Risk Factors for Depression in Terminally Ill Patients Poorly controlled pain Progressive physical impairments Medication side effect – Steroids, benzodiazepines, some chemotherapy agents Malignancy – Patients with breast, lung or pancreatic cancer have higher incidence of depression Age – Younger patients with cancer are more likely to be depressed than older patients Prior personal or family history of depression Lack of social support

6. Differential Diagnoses of Depression Adjustment disorder Bereavement Dementia Delirium (hypoactive)

7. Examples of Tools to Screen for Depression “Do you feel depressed most of the time?” ▫Sensitive and specific screening question Patient Health Questionnaire-9 (PHQ-9) Beck Depression Inventory

8. Management of Depression (1) Standard antidepressants effective but delayed onset of 2-6 weeks Selective serotonin reuptake inhibitors (SSRIs) have less side effects than tricyclic antidepressants (TCAs) – TCAs have anti-cholinergic side effects Psycho stimulants can be used if need rapid effect – Can be started at same time as SSRIs, which take longer to work – Beneficial effect on energy, mood, appetite, mental alertness – Trial of methylphenidate 2.5mg in early morning hours, up titrate if needed

9. Management of Depression (2) Electric Convulsive Therapy (ECT) – Induces seizures, releasing more epinephrine, serotonin, dopamine – Benefits: Effective, safe for rapid treatment of severe depression – Contraindications: CNS space occupying lesions Psychotherapy – Psychiatrist, psychologist, chaplain, social worker

10. Management of Depression (3) Complementary Therapies – Sunlight exposure – Aromatherapy – Relaxation therapy – Distraction therapy with pleasant imagery – Meditation – Guided imagery – Music therapy – Massage therapy

11. Anxiety: Introduction Anxiety is a state of feeling apprehension – Can lead to functional impairment & poor quality of life when excessive or persistent Present in up to 21% of cancer patients – Only a small % had any symptoms of anxiety prior to cancer diagnosis or treatment Often overlooked & not treated aggressively

12. Anxiety: Introduction (2) Generalized anxiety disorder (GAD) is diagnosed when excessive anxiety or worry lasts 6+ months & impacts day-to-day activities. Often co-occurs with adjustment disorders & depression Cancer patients may develop hyper arousal & nightmares and meet criteria for Posttraumatic Stress Disorder (PTSD)

13. Signs and Symptoms of Anxiety Excessive worry, apprehension, foreboding Irritability, tension Agitation, restlessness, hyper arousal Insomnia Sweating, tachycardia Hyperventilation, shortness of breath Gastrointestinal distress, nausea

14. Screening for Anxiety Screening questions ▫“Do you find yourself worrying a lot?” ▫“Are you often fearful?” ▫“Do often feel anxious?” Obtain collateral information

15. Examples of Some Reversible Causes of Anxiety Alcohol Caffeine Medication side effect – Levothyroxine, antipsychotics, psycho stimulants, steroids, beta-agonists Pulmonary embolus Uncontrolled pain Hypoxia Abnormal metabolic status Withdrawal from nicotine, alcohol, opioids Cardiac arrhythmias

16. Management of Anxiety Treat reversible causes Complementary or alternative therapy ▫Guided imagery, meditation, music, aromatherapy, massage therapy Supportive counseling Coping techniques Limit caffeine, alcohol Pharmacologic management

17. Benzodiazepines (BZs) Can be used when immediate relief is desired ▫Choose based on desired half-life ▫Examples of common BZs  Clonazepam (half-life: 30-40 hrs)  Example dosing: 0.5-2mg po daily to BID prn  Lorazepam (half-life: 12 hrs)  Example dosing: 0.25mg-2mg po / SL q 6h PRN ▫Taper slowly when discontinuing  (e.g. reduce dose by 25-50% each day)

18. Gapabentin & Trazodone Alternative options with BZs contraindicated or when primary hypnotic effect desired ▫Gabapentin 300mg po qHS  Increase dose every 3-5 days if ineffective, first to 300mg po q12h, then 300mg po q8h, then by increments of 100mg q 8h  Max dose is 3,600mg/day (use with caution in elderly) ▫Trazodone 12.5mg po q2hr prn anxiety/agitation ▫Trazodone 25-100mg po qHS for insomnia

19. Selective Serotonin Reuptake Inhibitors (SSRIs) Can be used for chronic anxiety Higher doses may be needed to manage chronic anxiety Example: paroxetine, citalopram, escitalopram

20. Paroxetine Often chosen due to sedating, calming effect Initial starting dose 10-20mg po daily Target is 20-40mg daily Max 50mg/day Use extended release formulation to reduce risk of adverse events

21. Citalopram (Celexa) Starting dose 10-20mg daily Increase weekly by 10-20mg daily In elderly, max dose is 20mg daily In patients < 65, usual target is 40mg daily. Max is 60mg/day Black box warning: Prolonged QTc interval, increased risk of mortality in elderly

22. Escitalopram (Lexapro) Starting dose: 5-10mg daily Maintenance & maximum dose: 10-20mg daily

23. For severe anxiety, consider starting both benzodiazepine and SSRI together ▫Once SSRI becomes effective in 4-6 weeks, then benzodiazepine can be tapered off Consult psychiatrist when benzodiazepine discontinuation is complicated

24. References & Suggested Readings EPEC (Education for Physicians on End-of-Life Care): Anxiety at http://www.cancer.gov/cancertopics/cancerlibrary/epeco/selfstudy/modul e-3/module-3c-pdf EPEC (Education for Physicians on End-of-Life Care): Depression at http://www.cancer.gov/cancertopics/cancerlibrary/epeco/selfstudy/modul e-3/module-3h-pdf Morrison RS, Meier DE. Clinical Practice: Palliative Care. N Engl J Med. 2004 Jun 17;350(25):2582-90